Varicocele

VARICOCELEVARICOCELE

NORMAL ANATOMYOF NORMAL ANATOMYOF PAMPINIFORM PLEXUSPAMPINIFORM PLEXUS

Union of multiple spermatic veins frm back of testis Union of multiple spermatic veins frm back of testis and epididymis.and epididymis.

Ascend along cord infront of the ductus deferens Ascend along cord infront of the ductus deferens below the superficial inguinal ring.They unite to form below the superficial inguinal ring.They unite to form 3-4 veins--inguinal canal—enter abdo thru deep 3-4 veins--inguinal canal—enter abdo thru deep ring--forms 2 veins which unite—testicular vein--ring--forms 2 veins which unite—testicular vein--IVC—acute.IVC—acute.

Drain from testes,epididymis and vas deferens-drain Drain from testes,epididymis and vas deferens-drain into spermatic veinsinto spermatic veins

Left spermatic vein drains into renal vein and right Left spermatic vein drains into renal vein and right spermatic into inferior vena cava and then into the rt spermatic into inferior vena cava and then into the rt renal vein.renal vein.

NORMAL ANATOMYNORMAL ANATOMY

What is varicocele?What is varicocele?

Dilatation and tortuosity of the pampiniform Dilatation and tortuosity of the pampiniform plexus and so also of the testicular veins.plexus and so also of the testicular veins.

Seen commonly in men aged 15-30yrs and Seen commonly in men aged 15-30yrs and rarely after 40yrs.rarely after 40yrs.

Occur in 15-20% of all males and 40% of all Occur in 15-20% of all males and 40% of all infertile males.infertile males.

Normal small vessels of plexus- 0.5-1.5mm. Normal small vessels of plexus- 0.5-1.5mm. Diameter greater than 2mm- Varicocele.Diameter greater than 2mm- Varicocele.

Seen commonly on the left side –5 reasons.Seen commonly on the left side –5 reasons.

-longer-longer

-enters at right angle to the renal vein-enters at right angle to the renal vein

-left testicular artery arching over it-left testicular artery arching over it

-a loaded sigmoid colon.-a loaded sigmoid colon.

- compressed b/w the aorta and SMA.- compressed b/w the aorta and SMA.

Aetiology and typesAetiology and types 1.IDIOPATHIC/PRIMARY – due to 1.IDIOPATHIC/PRIMARY – due to

incompetency of valves. 98% occur on the left incompetency of valves. 98% occur on the left side.side.

2.SECONDARY- pelvic or abdominal mass.2.SECONDARY- pelvic or abdominal mass. - L renal cell carcinoma with - L renal cell carcinoma with

tumor thrombus in left vein.tumor thrombus in left vein. --Nutcracker syndrome-Nutcracker syndrome- SMA SMA

compressing left vein. Common conditions- compressing left vein. Common conditions- RCC, Retroperitoneal fibrosis or adhesions.RCC, Retroperitoneal fibrosis or adhesions.

CLINICAL FEATURESCLINICAL FEATURES

Swelling Swelling Dragging /aching pain in the groin and Dragging /aching pain in the groin and

scrotumscrotum ““ bag of worms” feelingbag of worms” feeling Scrotum on the affected side hangs down.Scrotum on the affected side hangs down. On lying down,it gets reduced.On lying down,it gets reduced. Bow sign- hold varicocele b/w thumb and Bow sign- hold varicocele b/w thumb and

fingers,patient is asked to bow-reduced in size.fingers,patient is asked to bow-reduced in size.

Cough impulse presentCough impulse present Long standing cases- affected side testis is Long standing cases- affected side testis is

reduced in size and softer.reduced in size and softer. Fertility problems.Fertility problems.

Varicocele and subfertilityVaricocele and subfertility

Altered heat exchange mechanism due to Altered heat exchange mechanism due to stagnation- hyperthermia-inhibition of stagnation- hyperthermia-inhibition of spermatogenesis.spermatogenesis.

Increased temperature-increased metabolic Increased temperature-increased metabolic activity-depletion of glycogen storage-injury activity-depletion of glycogen storage-injury of parenchyma of testis-oligospermia.of parenchyma of testis-oligospermia.

Hypoxia, Leydig cell dysfunction-low Hypoxia, Leydig cell dysfunction-low testosterone.testosterone.

Maturation arrest-poor spermatogenesis.Maturation arrest-poor spermatogenesis.

INVESTIGATIONSINVESTIGATIONS

Venous doppler of the scrotum and groin-Venous doppler of the scrotum and groin-

-standing/ valsalva’s manouevre.-standing/ valsalva’s manouevre. U/S abdomen to look for kidney tumours.U/S abdomen to look for kidney tumours. Semen analysisSemen analysis

GRADINGGRADING

1.SMALL - identified only by bearing 1.SMALL - identified only by bearing down i.e, an increase down i.e, an increase in abdominal pressure.in abdominal pressure.

2.MODERATE - identified by palpation w/o 2.MODERATE - identified by palpation w/o bearing down.bearing down.

3.LARGE - easily identifed by inspection 3.LARGE - easily identifed by inspection alone.alone.

4.SEVERELY TORTUOUS.4.SEVERELY TORTUOUS.

INDICATIONS FOR SURGERYINDICATIONS FOR SURGERY American Urological Society recommends that American Urological Society recommends that

varicocele treatment should be offered to the varicocele treatment should be offered to the male partner of a couple attempting to male partner of a couple attempting to conceive when all of the following are present.conceive when all of the following are present.

A varicocele is palpable.A varicocele is palpable. The couple has documented infertility.The couple has documented infertility. The female has normal fertility or potentially The female has normal fertility or potentially

correctable infertility.correctable infertility. The male partner has one or more abnormal The male partner has one or more abnormal

semen parameters or sperm function test semen parameters or sperm function test results.results.

The indications in adolescents- presence of The indications in adolescents- presence of significant testicular asymmetry (>20%) significant testicular asymmetry (>20%) demonstrated on serial examinations, testicular demonstrated on serial examinations, testicular pain, and abnormal semen analysis results. pain, and abnormal semen analysis results. Very large varicoceles may also be repaired; Very large varicoceles may also be repaired; however, in the absence of atrophy, this however, in the absence of atrophy, this indication is relative and controversialindication is relative and controversial . .

TREATMENTTREATMENT 3 SURGICAL AND 1 NON SURGICAL 3 SURGICAL AND 1 NON SURGICAL

PROCEDURE.PROCEDURE.

VARICOCELECTOMY- VARICOCELECTOMY- The most common approaches are The most common approaches are  inguinal (groin)-easier and safer. inguinal (groin)-easier and safer.  retroperitoneal (abdominal) retroperitoneal (abdominal) infrainguinal/subinguinal (below the groin),infrainguinal/subinguinal (below the groin), suprainguinal extraperitonial( Palomo’s operation), suprainguinal extraperitonial( Palomo’s operation), Scrotal approach- grade 4. Scrotal approach- grade 4.

Done in GA or Done in GA or spinal.spinal.

2-3 inch incision.2-3 inch incision. Ligate the offending Ligate the offending

veins.veins. Avoid strenuous Avoid strenuous

exercise for several exercise for several days after surgery.days after surgery.

Apply scrotal Apply scrotal support.support.

ComplicationsComplications 20% chance of recurrence.20% chance of recurrence. 5% chance of hydrocele5% chance of hydrocele Damage to testicular artery.Damage to testicular artery. Infection.Infection. hematomahematoma

2. MICRODISSECTION2. MICRODISSECTION

Microsurgery (also called microsurgical ligation) Microsurgery (also called microsurgical ligation) smaller incision is made.smaller incision is made.

Cut the skin and fatty tissue. Because muscle is not Cut the skin and fatty tissue. Because muscle is not cut-less pain and faster recovery. cut-less pain and faster recovery.

The doctor identifies the varicoceles (swollen veins) The doctor identifies the varicoceles (swollen veins) through an operating microscope. Large varicoceles through an operating microscope. Large varicoceles are cut and stapled closed. Smaller varicoceles are cut are cut and stapled closed. Smaller varicoceles are cut and stitched shut. and stitched shut.

Takes less than an hour and recovery time is short. Takes less than an hour and recovery time is short.  Higher success rate,fewer complications,smaller scar.Higher success rate,fewer complications,smaller scar.

3.LAPROSCOPY3.LAPROSCOPY

Similar to conventional surgery. Incision made Similar to conventional surgery. Incision made on abdomen.on abdomen.

High ligations required.High ligations required. Larger incision or more retraction needed.Larger incision or more retraction needed. Complications more- testicular artery injuryy Complications more- testicular artery injuryy

and hydrocele.and hydrocele.

IV. Coil Embolization, Radiologic IV. Coil Embolization, Radiologic Balloon Occlusion or Radiologic Balloon Occlusion or Radiologic

Ablation Ablation  Non-surgical procedure.Non-surgical procedure. Steel coil or silicone balloon catheter is Steel coil or silicone balloon catheter is

introduced into a vein below the groin through introduced into a vein below the groin through a nick in the skin.a nick in the skin.

Passed under X-ray guidance.Passed under X-ray guidance. Tiny metal coils or other embolizing agents Tiny metal coils or other embolizing agents

introduced through the catheter.introduced through the catheter.

No stitches needed. No stitches needed. Patient can go back in 24hrs.Patient can go back in 24hrs. Lower rates of complications.Lower rates of complications.

Disadv- less effective, higher recurrence(5-Disadv- less effective, higher recurrence(5-11%), 11%), danger that the coil could migrate to the danger that the coil could migrate to the heart and cause deathheart and cause death . .

CONTRAINDICATIONSCONTRAINDICATIONS

Subclinical varicocele in an infertile person-Subclinical varicocele in an infertile person-controversial.controversial.

discovery of a varicocele at the time of discovery of a varicocele at the time of vasectomy or vasectomy reversal-relative vasectomy or vasectomy reversal-relative contraindication to immediate repair. contraindication to immediate repair.

A 6-month delayed repair is recommended -to A 6-month delayed repair is recommended -to allow the development of collateral vessels to allow the development of collateral vessels to decrease the chance of vascular compromise to decrease the chance of vascular compromise to the testicle.the testicle.